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Chapter 1 Preventive health care
Introduction
Preventive health-care centers on disease prevention and health maintenance. It encompasses routine health assessments of risk factors for the development of diseases, the early diagnosis of diseases, counseling regarding risk factors and disease identification, and other interventions or tests to prevent a health problem. Physical examination, screening tests, health education, and immunization programs are common examples of preventive health care. The common screening tests and recommendations for women are outlined and addressed in this chapter.
The annual examination
Every patient contact can be an opportunity to promote good health, but the annual exam should focus on disease prevention. A multitude of guidelines exist, and the American College of Obstetricians and Gynecologists (ACOG) recommends an annual well-woman visit that includes screening, evaluation, counseling, and immunizations based on age and risk factors (available at www.acog.org/wellwoman).[1] The latest screening guidelines are regularly updated and published on the US Preventive Services Task Force website: www.uspreventiveservicestaskforce.org. The Affordable Care Act (ACA) is intended to help Americans gain access to routine screening services and regular wellness visits. Health plans are required to cover certain preventive services with no cost sharing from the patient.[2] For women these include:
well-woman exams on an annual basis
gestational diabetes screening
HPV DNA testing
sexually transmitted infection counseling
HIV screening and counseling
contraception and contraceptive counseling
breastfeeding counseling, support, and supplies
domestic violence screening
Basic well-woman examination
At each well-woman visit, the patient’s general health should be assessed along with investigation into risk factors for common and age-associated issues.
The patient’s history should include:
medical, surgical, mental, menstrual, and reproductive health
family medical history
use of medications
use of tobacco, alcohol, or drugs
sexual practices, including need for contraception
abuse/neglect/violence
diet and nutrition
exercise and physical activity
assessment of symptoms of age-related issues
The physical examination should include:
height
weight
BMI calculation
blood pressure
neck: for adenopathy and thyroid assessment
abdominal examination
breasts: beginning at age 20, every one to three years; yearly after age 40
pelvic: based on age or medical history
other physical examination as clinically indicated
Laboratory, imaging, and other tests should be done based on age and risk factors (see www.acog.org/~/media/Departments/Annual%20Womens%20Health%20Care/PrimaryAndPreventiveCare.pdf).[3]
Pelvic examination
ACOG recommends a pelvic exam annually in women 21 years and older even though no evidence supports or refutes its use in asymptomatic, low-risk patients. The decision whether or not to perform a pelvic exam in an asymptomatic patient should be a shared decision between the patient and her physician. A pelvic exam should be done in women with symptoms of pelvic, genital tract, urological, or gastrointestinal problems.[1]
Cancer screening
Screening for certain cancers allows for early detection and improves cure and survival rates. Here we address screening for cancers that have shown a benefit toward improved outcomes with minimal harm from testing.
Breast cancer
Breast cancer is the most common cancer diagnosed in women in the United States, and screening has effectively reduced breast cancer mortality. General screening recommendations apply to women who are not at increased risk for breast cancer by virtue of a known genetic mutation or history of chest radiation. Genetic mutations account for a small percentage of women diagnosed with breast cancer annually; increasing age is the most important risk factor breast cancer.[4]
Mammography
In 2009 the US Preventive Serviced Task Force (USPSTF) recommended mammogram screening every two years for women aged 50 to 74 years, with individualization of biennial screening for younger women (aged 40 to 49 years) based on personal circumstances and values.[5] The American Cancer Society (ACS) and ACOG strongly recommend yearly screening with mammography beginning at age 40 years.
Life expectancy and medical comorbidities should be taken into account when screening women over the age of 75. The benefits of mammography decrease compared to the harms of overtreatment with advancing age. At age 75, women in consultation with their physician should decide whether to continue or stop screening.[4]
Clinical breast examination
A clinical breast exam should be done yearly for women 40 years and older and every one to three years for women aged 20 to 39 years.
Breast self-examination and breast self-awareness
Breast self-examination (BSE) is a method for women to examine their own breasts in a systematic way on a regular basis. BSE has not been proven to reduce morbidity or mortality related to breast cancer and may increase harm related to biopsies for false positive findings. ACOG and the ACS promote breast self-awareness. It focuses on women knowing what is normal for their own breasts so that any change, even a small one, can be recognized and reported to a health-care provider.
Enhanced screening for women at increased risk
Women with a known BRCA 1/2 mutation, 20% risk of breast cancer based on risk models, or personal history of breast cancer, as well as those who had thoracic radiation require enhanced surveillance for breast cancer. This includes twice yearly clinical breast exams, a yearly mammogram, a yearly breast MRI, and instruction on breast self-examination. For those women at risk due to thoracic radiation, screening should begin 8 to 10 years after they received treatment or at age 25, whichever occurs latest.[4]
Prevention of breast cancer in women at increased risk
Physicians should counsel and prescribe risk-reducing medications, such as tamoxifen or raloxifene, for women at increased risk for breast cancer and low risk for adverse medication effects.[6]
Cervical cancer
Routine screening with cervical cytology (Pap test) has reduced the incidence and mortality for cervical cancer in the United States by more than 50%.
Screening with cervical cytology should start at age 21, with Pap tests every three years through age 29. From age 30 to 65 years, women should have a Pap test simultaneously with a high-risk (oncogenic) human papillomavirus (HPV) test every five years or a Pap test alone every three years. Women aged 21 to 29 years should not be screened with HPV testing unless it is used to triage an abnormal result. Women younger than 21 years of age should not be screened regardless of the age of onset of sexual activity. Women who have undergone a hysterectomy and retain their cervix should continue routine age-based surveillance. Women with a previous history of CIN II or higher should continue to undergo routine age-based screening for 20 years beyond the initial posttreatment surveillance period even if that takes them beyond 65 years of age.
Woman with HIV infection should be screened twice a year in the first year after diagnosis, then annually thereafter. The Centers for Disease Control and Prevention (CDC) recommends initiating screening the year that diagnosis is made, even if the woman is younger than 21. There are no guidelines for screening in women who are immune-compromised due to other diseases or conditions, so beginning annual screenings at age 21 should be sufficient.
Colorectal cancer
Colorectal cancer (CRC) is the third leading cause of death among women in the United States. Although rectal bleeding is the most common symptom, most people diagnosed with colon cancer do not have symptoms. The American College of Gastroenterology (ACG) recommends both cancer prevention tests that can find cancer as well as polyps and cancer detection tests that have lower sensitivities for polyps and cancer (Table 1-1). Overall, the preferred screening method is colonoscopy every 10 years beginning at age 50, except for African Americans, who should begin screening at age 45. Detection tests may be used if a patient declines a prevention test or if prevention tests are not available to the patient. Women at higher risk for colon cancer due to strong family history, familial adenomatous polyposis (FAP) or hereditary non polyposis colorectal cancer (HNPCC) require more rigorous surveillance. Heavy cigarette smoking and obesity are linked to higher risk of CRC and occurrence at an earlier age. Therefore, consideration for earlier screening (possibly beginning at age 45) should be made on an individual basis for women who are heavy smokers or obese.[8]
| Starting age | Tests | Frequency |
|---|---|---|
50 years; 45 years for African Americans | Prevention tests* | |
| Colonoscopy** | Every 10 years | |
| Flexible Sigmoidoscopy | Every 5–10 years | |
| CT Colonography | Every 5 years | |
| Detection tests | ||
| Fecal Immunochemical Test for blood (FIT)*** | Annually | |
| Fecal DNA | Every 3 years |
* Prevention tests should be offered first.
** Colonoscopy is the preferred prevention test.
*** Preferred detection test. Hemoccult Sensa – 3 patient-collected samples.
Ovarian cancer
Routine screening for ovarian cancer in asymptomatic women is not recommended. Women at high risk for ovarian cancer (BRCA gene mutation or family history suggesting hereditary cancer syndrome) should undergo genetic counseling to assess their risk and, if appropriate, be offered ovarian cancer screening. Screening with CA-125 and transvaginal ultrasound every six months has been recommended for high-risk patients, but it has not shown to improve survival rates. ACOG recommends offering risk-reducing salpingo-oophorectomy for BRCA1- or BRCA2-positive women by age 40.[9]
Lung cancer
Annual screening for lung cancer with low-dose computed tomography is recommended for adults aged 55 to 80 years who have at least a 30-pack-per-year smoking history and currently smoke or who have quit smoking within the past 15 years. Screenings should stop once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.[10]
Bone health and osteoporosis
Bone health
Women are five times more likely than men to develop osteoporosis, and women are twice as likely to have a fracture. ACOG recommends discussing bone health early in a woman’s life, starting at puberty and adolescence when women are at the peak bone-building stage. Adequate nutrition and regular physical activity are essential for strong bones.[11] Calcium and vitamin D affect bone quality, and adequate quantities should be consumed through diet or supplementation (Table 1-2).[12]
| Nutrient | Age | Recommended daily dietary intake |
|---|---|---|
| Calcium | 9–18 years 19–50 years >50 years | |
| Vitamin D | ≤70 years >70 years | 600 IU 800 IU |
Osteoporosis screening
DXA
Bone mineral density (BMD) screening should begin at age 65 for all women. A dual-energy x-ray absorptiometry (DXA) of the lumbar spine and hip is the gold standard for diagnosis. Screening should be done every two years. Postmenopausal women younger than 65 should be screened with DXA only if they have significant risk factors for osteoporosis and/or bone fracture (Tables 1-3 and 1-4).
| Risk factors | Test and frequency |
|---|---|
| ≥65 years | DXA every 2 years; FRAX yearly if osteopenia |
| <65 years postmenopausal with >1 risk factor* | DXA every 2 years; FRAX yearly if osteopenia |
| Current smoker | |
| Alcoholism | |
| Rheumatoid arthritis | |
* Risk factors:
Medical history of a fragility fracture
Body weight less than 127 lbs.
Medical causes of bone loss (medications or diseases)
Parental medical history of hip fracture
| Category | T-score* |
|---|---|
| Normal | ≥–1.0 |
| Osteopenia (low bone density) | <–1.0 to >–2.5 |
| Osteoporosis | ≤–2.5 |
* T-score is the number of standard deviations above or below the mean average bone density value for young adult women.
FRAX
The fracture risk assessment tool, FRAX (www.sheffield.ac.uk/FRAX) determines a patient’s probability of developing fracture in the next 10 years. It assesses risk based on BMD at the femoral neck and clinical factors. An annual FRAX score should be calculated to monitor the effect of age on fracture risk when osteopenia is diagnosed by DXA (Table 1-5).
FRAX score ≥3% for risk of hip fracture FRAX score ≥20% for risk of a major osteoporotic fracture (forearm, hip, shoulder, or clinical spine fracture) |
Heart and vascular health
Hypertension
Chronic hypertension is a common and significant health problem predisposing women to increased risks of heart disease, stroke, renal disease, and other vascular diseases. Blood pressure (BP) should be assessed at each visit, and the diagnosis of elevated blood pressure is made if abnormal readings are detected on two separate visits.[13]
It is necessary to be familiar with diagnostic criteria and treatment guidelines (Table 1-6).
| Classification | Systolic BP | Diastolic BP | Lifestyle modification | Initial drug therapy | |
|---|---|---|---|---|---|
| Without compelling indications | With compelling indications** | ||||
| Normal | <120 | and <80 | Encourage | No drug therapy indicated | Drug(s) for compelling indications |
| Prehypertension | 120–139 | or 80–89 | Yes | ||
| Stage I hypertension | 140–159 | or 90–99 | Yes | Thiazide-type diuretics for most; may consider ACEI, ARB, BB, CCB, or combination | Drug(s) for compelling indications; other antihypertensive medications as needed |
| Stage II hypertension | ≥160 | ≥100 | Yes | Two-drug combination for most (usually thiazide-type diuretic and ACEI or ARB or BB or CCB) | |
Drug abbreviations: ACEI – angiotensin converting enzyme inhibitor; ARB – angiotensin receptor blocker; BB – beta blocker; CCB – calcium channel blocker.
Evaluation
Evaluation for end organ damage (Table 1-7), identifiable causes (Table 1-8), and cardiovascular risk factors should be done once hypertension is diagnosed. Treatment or referral for treatment should also occur.
| Physical exam |
| |
| Diagnostic tests and labs | Electrocardiogram Lipid profile Blood glucose Creatinine | Serum potassium Calcium Hematocrit Urinalysis |
|
Treatment
The fundamental goal of treatment is the reduction of cardiovascular and renal morbidity and mortality. The therapeutic BP target is <140/90 mmHg. In hypertensive patients with diabetes or renal disease, the BP goal is <130/80 mmHg. Lifestyles changes (Table 1-9) should be recommended for all patients with hypertension and are first line of treatment unless stage II hypertension or compelling indications exist. Many medications are available for treatment, but typically thiazide-type diuretics work for most patients (Table 1-10). African Americans respond better to diuretics and calcium channel blockers than the other classes of medications. Certain compelling indications respond better to certain classes of medications (Table 1-10).[14]
| Modification | Recommendation | Approximate SBP reduction |
|---|---|---|
| Weight loss | Maintain normal BMI 18.5–24.9 kg/m2 | 5–20 mmHg per 10 kg weight loss |
| DASH diet | Consume diet rich in fruits, vegetables, and low-fat dairy products with a reduced content of saturated and total fat | 8–14 mmHg |
| Reduce sodium intake | Reduce dietary sodium intake to no more than 2–4 gram sodium or 6 grams of sodium chloride daily | 2–8 mmHg |
| Physical activity | Engage in regular aerobic activity at least 30 minutes per day for most days of the week | 4–9 mmHg |
| Limit alcohol consumption | No more than 1 drink per day in women (2 drinks per day in men) | 2–4 mmHg |
DASH – dietary approach to stop hypertension.
| Compelling indication | Recommended drugs* | |||||
|---|---|---|---|---|---|---|
| Diuretic | BB | ACEI | ARB | CCB | AldoANT | |
| Chronic kidney disease | X | X | ||||
| Diabetes | X | X | X | X | X | |
| Heart failure | X | X | X | X | X | |
| High coronary disease risk | X | X | X | X | ||
| Postmyocardial infarction | X | X | X | |||
| Recurrent stroke prevention | X | X | ||||
Drug abbreviations: ACEI – angiotensin converting enzyme inhibitor; ARB – angiotensin receptor blocker; AldoANT – aldosterone antagonist; BB – beta blocker; CCB – calcium channel blocker.
* Compelling indications for antihypertensive drugs are based on benefits from outcome studies or existing clinical guidelines; the compelling indication is managed in parallel with the hypertension.
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